Amputations of foot and it's rehabilitation.pptx

Amputation at various levels of foot.

1. DEFINITION Amputation - SURGICAL ABLATION OF BODY PART THROUGH ONE OR TWO BONE. Disarticulation - surgical ablation of body part through joint.

2. Indication of amputation: Peripheral vascular disease Trauma Burns Frostbite Infection Tumors Neuropathy Congenital limb deficiency

3. SALVAGIBILITY OF A LIMB VARIOUS SCORING SYSTEM- PREDICTIVE SALVAGE INDEX LIMB SALVAGE INDEX LIMB INJURY SCORE MANGLED EXTREMITY SEVERITY SCORE

4. SCORE<6- SALVAGEABLE; SCORE>7- HIGHLY PREDICTIVE OF AMPUTATION

5. PRE-OP CARE: Nutritional status of the patient Limb perfusion Serum albumin OF ATLEST 3.5 G/DL Total lymphocyte count >1500/ML HEMOGLOBIN >10 GM/DL Diabetes control PRE OPERATIVE COUNSELLING REHABILITATION ASSESSMENT PROXIMAL JOINT FUNCTION SHOULD BE NORMAL.

6. INTRA-OP CARE: AVOID EXCESSIVE PRESSURE ON SKIN EDGES. Thick skin flap. BONY PROMINENCES SHOULD BE REMOVED. Controlling hemostasis. CLOSURE SHOULD BE DONE WITHOUT TENSION AT MARGIN. PRESERVE AS MUCH LENGTH IS POSSIBLE.

7. POST-OP CARE: DRESSING LIKE HYDROCOLLOID, HYDROGEL, ALGINATE ETC. BIOLOGICAL DRESSING LIKE ALLOMATRIX AND GRAFTJACKET REGENERATIVE TISSUE MATRIX. VACCUM ASSISTED CLOSURE IS ALSO BENEFICIAL IN LARGER WOUND MEASURES TO PREVENT CONTRACTURES TO MAXIMIZE FUNCTION AND MINIMIZE COMPLICATION OF THE AMPUTED LIMB PEDORTHIST, ORTHOTIST AND PROSTHETIST MUST BE INVOLVED.

8. GOALS OF AMPUTATION: ABLATION OF DISEASE TISSUE RECONSTRUCTION PROVIDE PHYSIOLOGICAL END ORGAN OPTIMIZE PATIENT FUNCTION AND REDUCE MORBIDITY.

9. Amputation of foot: Toe amputation or disarticulation Metatarsal phalangeal disarticulation Transmetatarsal amputation Lisfranc amputation Chopart amputation Syme amputation Boyd’s amputation

10. Toe amputation: AMPUTATION OF GRAET TOE : WHILE STANDING OR WALKING NORMALLY- FUNCTIONALLY NO EFFECT. WHILE RUNNING- LIMP APPEARS. AMPUTATION OF 2 ND TOE : CAUSES SEVERE HALLUX VALGUS. TO PREVENT SCREW FIXATION IS USED. AMPUTATION OF ALL TOE : WHILE SLOW WALKING- LITTLE DISTURBANCE. WHILE RAPID GAIT- DISABLING. INTERFERES IN SQUATING AND TIPTOEING. NO PROSTHESIS IS REQUIRED OTHER THAN SHOE FILLER.

11. TERMINAL SYME AMPUTATION: INDICATION : HALLUX TERMINAL ULCERATION, CHRONIC INGROWN NAILS WITH PARONYCHIA, HALLUX TUFT OSTEOMYELITIS OR TRAUMATIC INJURY TO TIP OF HALLUX. REMOVING DISTAL ASPECT OF DISTAL PHALYNX OF HALLUX RETAINING EXTENSOR HALLUCIS LONGUS AND FLEXOR HALLUCIS LONGUS INSERTION.

12. AMPUTATION AT BASE OF PROXIMAL PHALYNX

13. Metatarsal phalangeal disarticulation: Long plantar and short dorsal skin flap. For 1 st metatarsal incision starting medially and curve it distally over the lateral and posterior aspect. For 5 th metatarsal incision starting laterally and curve it distally over medial and posterior aspect.

14. Transmetatarsal amputation: Ray amputation- toe amputation with head of metatarsal. Gillies’ amputation- t RANSMETATARSAL with PROXIMAL TO NECK OF METATARSAL, DISTAL TO BASE of metatarsal.

15. Prosthesis for toe amputation

16. MIDFOOT AMPUTATION AMPUTATION THROUGH MIDFOOT INCLUDE LISFRANC AMPUTATION AT TARSOMETATARSAL JOINTS AND CHOPART AMPUTATION AT TRANSVERSE TARSAL JOINT. MIDFOOT AMPUTATION LEAD TO SEVERE EQUINOVARUS DEFORMITY.

17. Lisfranc amputation Tarsometatarsal disarticulation. LEAD TO SEVERE EQUINOVARUS DEFORMITY. TO PREVENT EQUINOVARUS DEFORMITY- PRESERVE INSERTION OF TIBIALIS ANTERIOR AND PERONEUS LONGUS AT MEDIAL CUNEIFORM AND PERONEUS BREVIS AT THE BASE OF 5 TH METATARSAL. BASE OF 2 ND METATARSAL SHOULD BE SPARED TO PRESERVE PROXIMAL TRANSVERSE ARCH.

18. Chopart amputation: DISARTICULATION OF TALO-NAVICULAR & CALCANEO-CUBOID JOINTS. To prevent equinovarus deformity- One or more dorsiflexors must be transferred. Decrease strength of achilles tendon. Position the stump in slight dorsiflexion and rigid dressing for 6 weeks. Alternatively, ankle arthrodesis may be done immediately.

19. CHOPART FRACTURE Transfer TIBIALIS ANTERIOR tendon to lateral aspect of neck of talus, using bone tunnel with biotenodesis screw and using a suture anchor or staple to secure fixation. Transfer extensor hallucis longus to anterior process of calcaneus.

20. Prosthesis for chopart amputation

21. Hindfoot and ankle amputation Goal is to produce end bearing stump and enough space between end of stump and ground for construction of some type of ankle joint mechanism for artificial foot. Types- Syme amputation Boyd amputation Pirogoff amputation

22. Syme amputation Bone transection at distal tibia and fibula 0.6 cm proximal to periphery of ankle joint and passing through the dome of the ankle centrally. The tough durable skin of heel flap provides normal weight bearing skin. Sarmiento modified syme procedure by transecting tibia and fibula 1.3 cm proximal to ankle joint and excision of medial and lateral malleolus to produce less bulbous stump and allow use of more cosmetic prosthesis.

23. Syme’s amputation Can be done in- One stage - original / classic Syme's amputation. Two stage- in case of gross infection of forefoot. Modified amputation- modified to get a less bulbous and more cosmetic stump by removing metaphyseal flare of tibia and beveling distal end of fibula.

24. Syme’s amputation

25. SYME’S AMPUTATION

26. SYME’S AMPUTATION

27. Syme’s prosthesis PROSTHESIS CONSIST OF MOLDED PLASTIC SOCKET WITH REMOVABLE MEDIAL WINDOW TO ALLOW PASSAGE OF BULBOUS END OF STUMP THROUGH ITS NARROW SHANK.

28. BOYD’S AMPUTAION To produce excellent end bearing stump and eliminates the problem of posterior migration of the heel pad that occurs after Syme amputation. It involves talectomy, Excision of anterior part of calcaneus, distal to peroneal tubercle. forward shift of calcaneus and calcaneo -tibial arthrodesis by using Steinmann pin or cannulated screw.

29. PiRiGOFF AMPUTATION Involves arthrodesis between tibia and part of calcaneus. Calcaneus is sectioned vertically, removing anterior part and rotating posterior portion with heel pad forward and upward 90* to meet denuded distal end of tibia.